Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.


Making Newborn Rounds

Candace F. Zickler

Asthma, 493.9

Jaundice, 774.6

Breathing diffi culties, 786.09

Meconium stools, 777.1

Café au lait spots, 709.09

Nares patent (choanal atresia), 748

Coarctation of aorta, 747.1

Neck short/masses (cystic hygroma),

Cyanosis, 770.83


Cytomegalovirus (CMV), 078.5

No urine in 12 hours, 788.2

Decreased bowel movements, 564

Pallor, 782.61

Epispadius, 752.62

Petechiae, 772.6

Gestational diabetes (GD), 648.8

Poor feeding, 779.3

Gonorrhea, 098

Port wine stain, 757.32

Group B streptococcus, 041.02

Pregnancy-induced hypertension

Heart rate with murmur, 785.2

  (PIH), 642.9

Hemangioma, 228.01

Rash or pustules, 782.1

Hematoma/caput succedaneum, 767.19

Rubella, 056.9

Herpes simplex virus (HSV), 054.9

Seizures, 779

Human immunodefi ciency virus (HIV),

Sickle cell disease, 282.6


Spontaneous abortions, 634.9

Hypoglossia/macroglossia, 529.8

Stillbirths/perinatal deaths, 779.9

Hypospadias, 752.6

Supernumerary nipples, 757.6

Infant galactosemia, 271.1

Toxoplasmosis, 130.9

Infertility, 628.9

Umbilicus with hernia, 553.1

Irritability, 799.2

Vomiting, 787.03


A. Determine number of newborns delivered in last 24 hours.

B. Prioritize assessments by birth time and concerns of nurses.

C. Evaluate each infant within 12-24 hours of age and daily until discharge.


A. Mother.

1. Past obstetric history: infertility, spontaneous abortions, stillbirths/perinatal deaths, parity, gravity, length of pregnancy, congenital anomalies in other infants, assistive reproductive technology (ART) used, isoimmune disease (Rh, ABO), pregnancy-induced hypertension (PIH), Cesarean births, vaginal birth after Cesarean, gestational diabetes. Current pregnancy history: maternal age, overall health (asthma, sickle cell disease), estimated date of confinement (EDC), prenatal care, number of previous pregnancies, multiple or single fetus, presentation/position of fetus, amount of amniotic fluid, fetal growth/size (small, appropriate, or large for gestational age), nationality, public assistance.

2. Results of prenatal lab work: blood type; rubella IgG level; hepatitis B immunization status; serologic tests; HIV status (elective); gonorrhea and chlamydia cultures; maternal alpha fetal protein; urinalysis (bacteria, blood, protein); glucose screen; exposure to drugs, alcohol, tobacco, or teratogenic medications (valproate, tetracycline); exposure to viruses (TORCH: toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus); sexually transmitted infections; Group B streptococcus status.

B. Newborn.

1. Prenatal history: vaginal or Cesarean delivery; length of labor and delivery; tocolytics used during labor; narcotics, anesthesia, or analgesics mother received; presentation; placental abnormalities (three-vessel cord); amniotic fluid color/volume; Apgar scores (heart rate, respirations, muscle tone, reflex irritability, color) with 5-minute Apgar > 7.

2. Since birth: delivery weight/length/occipital frontal circumference (OFC), temperature, blood pressure, pulse, respirations, feeding/nursing with breast or bottle, voiding spontaneously, passage of meconium, infant contact with mother/parents.


A. General appearance.

1. Current weight, length, OFC, color, heart rate, respirations, temperature, blood glucose at birth, response to stimuli, posture, determination of gestational age from the New Ballard Score (physical maturity and neuromuscular maturity).

B. Full-term infant > 37 weeks but < 42 weeks, premature infant < 37 weeks, late preterm infant> 34 weeks to 36 weeks and 6 days, post-term infant> 42 weeks.

C. Late preterm infants at greater risk for airway instability when upright, respiratory distress, apnea/bradycardia, excessive sleepiness, excessive weight loss, poor feeding, hyperbilirubinemia, hypoglycemia, hypothermia, sepsis, weak suck, and rehospitalization.


A. Dysmorphic facies hyper- or hypotelorism, epicanthal folds, symmetrical facies and extremities.

1. Skin and scalp with plethora, pallor, jaundice, cyanosis, bruising, abrasions, petechiae, hemangioma, port wine stain, café au lait spots.

2. Shape of skull.

3. Bruising, hematoma/caput succedaneum.

4. Size and tone of anterior and posterior fontanels.

B. Pupils without red reflex and unequal pupillary sizes, nares patent (choanal atresia), mouth with teeth, hypoglossia/macroglossia, palate high arched or missing. External ears with tags or pinhole openings. Neck short/masses (cystic hygroma) or webbing.

C. More/less than five fingers/toes on each hand/foot.

D. Check clavicles for fractures. Chest shape with pectus excavatum/carinatum, and supernumerary nipples. Breath sounds that are moist and grunting/ retractions after 4 hours of age, apnea/respirations < 30 or > 60 per minute.

E. Heart rate with murmur (soft III/IV systolic murmur normal for first 1224 hours since patent ductus may not be closed), or an irregular rate/rhythm < 100 > or 180 bpm, a cuff blood pressure < 65 or > 95 mm Hg of systolic pressure, and diastolic < 30 or > 60 mm Hg. Absent or decreased femoral pulses (coarctation of aorta), slow capillary refill is indicative of poor perfusion.

F. Temperature instability < 97.7°F (36.5°C) after 4 hours of age.

G. Abdominal skin thin or missing, asymmetrical, distended, umbilicus with hernia, discharge, redness, odor. Missing or overactive bowel sounds. Lower liver edge 3 cm below costal margin (heart disease), infection, hemolysis, palpable spleen (infection or hemopoiesis), enlarged bladder (1-4 cm above symphysis).

H. Female.

1. Masses in labia (hernia, enlarged Bartholin gland), vesicles.

I. Male.

1. Meatal opening on penis placed abnormally (hypospadias or epispadius), absence of testes in either inguinal canals or scrotal sac, hydrocele, bifid scrotum, discoloration, or bruising.

J. Anus absent or not patent.

K. Absent or missing extremities, bands, masses, inequality from side to side. Abnormal Ortolani or Barlow sign. Bowing of extremities, abnormal foot positions, flaccid upper extremity. Lesions or dimpling of lower spine.

L. Abnormal posturing, floppy or very jittery, abnormal cry. Exaggerated tonic neck, Moro reflex, poor sucking, or poor rooting.


A. Glucose screening (normal 40-90 mg/dL), venous hematocrit (normal 45-65%), cord blood (ABO, Rh). If baby is Rh-, maternal RhoGAM status should be Rh+.

B. Bilirubin: Determine etiology of any jaundice, i.e., physiologic or pathologic. Obtain baseline total serum bilirubin, plus a direct and indirect level.

Sixty percent of all term newborns and 80% of preterm infants will have some jaundice in the first week of life.

Any jaundice within the first 24 hours after birth is considered pathologic. If the total serum bilirubin (TSB) rises more than 5 mg/dL/day or is higher than 12 mg/dL in full-term infants or 10-14 mg/dL for preterm, further evaluation and treatment is indicated. If the infant has signs of sepsis, irritability, or lethargy, this needs further evaluation. In infants 25-48 hours old, a TSB level above 15 mg/dL is indicative of rapid rise and infant needs further evaluation. In infants 49-72 hours old a TSB above 18 mg/dL or any infants more than 72 hours old with a TcB of 20 mg/dL needs further evaluation and treatment.7

When obtaining serial bilirubins, utilize noninvasive transcutaneous (TcB) bilirubinometer and nomogram.

C. Newborn hearing screening. To be done no later than 1 month of age. Most hospitals offer this screening for newborns prior to discharge. Risk factors for infants include family history of sensorineural hearing loss, in utero infections (TORCH), craniofacial anomalies, hyperbilirubinemia, post natal bacterial meningitis, findings indicative of a syndrome with hearing loss, neurodegenerative disorders, sensory motor neuropathies, parental concerns for hearing, head trauma, and recurrent/persistent otitis media. If infant fails the hearing screening, an audiologic evaluation needs to be done as follow up by 3 months of age.


A. Introduce self, sit by bedside. Describe your role. Answer parent's questions, describe the general process of how you will be working with them over the next day or so.

B. Praise parents, compliment baby.

C. Call baby by name.

D. Determine mother's health/wellness/contact with infant so far.

E. Review your findings, briefly.

F. If male, determine if baby is to be circumcised. Discuss pros and cons.

G. Ask about method of feeding, car seat, help when home, concerns.


A. Breastfeeding is encouraged for all newborns (see Chapter 5). Late preterm infants may not be as vigorous an eater as expected and may need close monitoring of weight. Obtain a breastfeeding consult and encourage nursing every 2 hours around the clock until infant is nursing at least 20 minutes during feedings.

1. No breastfeeding if HIV infected, active herpes of breast, untreated tuberculosis, maternal debilitating disease (cancer), illicit drug use by mother, infant galactosemia.

B. If bottle-feeding, reassure that baby will grow and thrive on formula.

1. Only commercially prepared, iron-fortified formulas should be used: powder, concentrate, ready-to-feed. Do not dilute ready-to-feed; do not reuse if > 4 hours since opened.

2. Mix formulas with bottled water for first month, continue if on well or unsure of water quality. Store in refrigerator if open no longer than 24 hours.

3. Specialized formulas have similar preparation directions. Goat's milk, whole cow's milk, rice milk have inadequate amounts of vitamins and minerals.

4. Serve formula at room temperature. Do not microwave to heat. Do not let formula sit out at room temperature to warm for more than 15-20 minutes.

C. Clean technique is sufficient for mixing formulas. Clean off cans with soap and water before opening. Use hot soapy water and bottlebrush to clean nipples and bottles or clean in dishwasher.

D. Hold during feedings; burp every 1-2 oz.

E. Hold in upright, semi-reclined position for feedings. No bottle propping.

F. Newborn will suckle 0.5-1 oz of formula/feeding every 2-3 hours for first 24 hours (60-100 mL/kg/day). Volume increases to 12-24 oz/day and interval between feedings > 3-4 hours in first month. May be days when baby takes more or less, depending on sleep pattern. Baby should take in 90% of feeding in first 20 minutes.


A. Meconium stools in first 48 hours, transition stools green-brown, change to yellow pasty after 2-3 days of oral feeding.

B. Infant should have 1-6 yellow pasty stools for 24 hours.

C. Breastfed baby may have upper range of frequency, bottle-fed may have less.

D. Void every 1-3 hours or with each feeding and diaper change.


A. Awake for feedings; feed every 2-4 hours. Should be alert, nurse vigorously for 15-20 minutes, then fall back to sleep. Respirations may be slightly irregular.

B. Babies should sleep on back in their crib. No pillows/toys in the crib that baby could get face against and be smothered.

C. Babies should sleep in own cribs, not with parents, to minimize potential for rollovers, suffocation, and falls.


A. Newborn can lose up to 10% of body weight in first 10 days of life. Should regain birth weight by 2 weeks of age.

B. Infant grows 1 in., on average, per month for first 6 months.

C. Head circumference increases 9 cm in first year.

D. Has minimal head control.

E. Looks at person during feeding.

F. Tracks 45°.


A. Babies have different cries, will fuss/cry 1 to 2 hours/day.

1. Similar time/pattern daily.

2. Provide for infant's needs and crying should cease.

3. Cry gradually decreases by 3 months of age.

B. Refer all high-risk infants/mothers to social worker before release. High-risk situations include:

1. Adolescent pregnancy.

2. No prenatal care.

3. Consideration about giving up the baby for adoption.

4. Unwanted pregnancy.

5. Insufficient support from those at home.

6. Physical limitations of parent.

7. Inadequate housing/finances.

8. Domestic violence.

9. Positive toxicology.

10. Incarcerated parent.

11. Emotional disorders.

12. Parent with mental retardation.

13. Multiple small children in home.


A. Only monovalent hepatitis B can be used for birth dose. If mother is hepatitis B surface antigen (HBsAg) positive, administer hepatitis B vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. If mother's HBsAg status is unknown, administer hepatitis B vaccine within 12 hours of birth and determine mother's HBsAg status as soon as possible. If she is then positive, the newborn should receive HBIG within 1 week of life. Monovalent hepatitis B should be given if second dose is given less than 6 weeks of age. Monovalent or combination vaccine can be used to complete series.


A. Sleep position “back to sleep.”

B. Not safe for baby to sleep in adult bed; must discuss with parents.

C. Use federal motor vehicle safety standards (FMVSS) tested and approved car seat; install properly in backseat, facing backward in automobile. Contact local hospital, fire department, or March of Dimes chapter for car seat rental program. Infants should ride in the rear-facing position in either an infant seat or a convertible car seat until they are at least 1 year of age and 20 lbs.

D. No smoking around infant.

E. One-piece pacifiers only.

F. No corn syrup (Karo) for constipation, but may give 1 oz of sterile water/ 24 hours.

G. No solids, only breastmilk or formula fed to infant.

H. When to call healthcare provider.

1. Breathing difficulties—too fast or too slow or color changes; seizures; irritability; poor feeding; vomiting; no urine in 12 hours; black or decreased bowel movements; reddened, draining umbilical site; jaundice; rash or pustules not present on discharge; concerns.

I. Give office phone number, explain how to use system.


A. Review all records/progress.

B. Repeat complete physical examination.

C. Identify abnormal findings that require ongoing monitoring.

D. Review hearing screening results and if not done, schedule before discharge.

E. Collect newborn blood screen.

F. Administer hepatitis B immunization.

G. Complete all consults.

H. Staff nurses will have covered discharge instructions of bathing, cord care, bulb syringe, diapering, dressing, fingernail care, holding, feeding.

I. If concerns, infants should be scheduled for office visit within two days, otherwise parents need a two-week follow-up appointment assigned before discharge. Make them comfortable knowing they can call with any concerns.


Ballard JL, Khoury JC, Wedeg K, et al. New Ballard Score expanded to Include extremely premature infants. Pediatrics. 1991;119:417-423.

Fouzas S, Mantagou L, Skylogianni SM, et al. (2009). Transcutaneous bilirubin levels for the first 120 postnatal hours in healthy neonates. Pediatrics. 2009;125(1):e52-e57. Retrieved from American Academy of Pediatrics website: Accessed June 2, 2011.

Car Safety Seats: A Guide For Families 2010. American Academy of Pediatrics Healthy Children website: Accessed June 2, 2011.

DeMichele AM, Ruth RA. Newborn Hearing Screening. Medscape Reference; 2010: Accessed June 2, 2011.

Hagan JF, Shaw JS, Duncan P, eds. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. American Academy of Pediatrics; 2008: Accessed June 2, 2011.

Porter ML, Dennis BL. Hyperbilirubinemia in the term newborn. Am Family Physician. 2002;65(4):599-607. American Academy of Family Physicians website: Accessed June 2, 2011.

Recommended Immunization Schedule for Persons Aged 0 through 6 Years–United States 2010. Centers for Disease Control and Prevention website: Accessed June 2, 2011.

Thureen PJ, Hall D, Deacon J, et al. Obstetric considerations in the management of the well newborn. In: Assessment and Care of the Well Newborn. 2nd ed. Philadelphia: W.B. Saunders; 2005:3-20.

Wolf A, Hubbard E, Stellwagen LM. The late preterm infant: A little baby with big needs. Contemporary Pediatrics. 2007;24(11):51-59.

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